Modernisation Muddles What is the Future of Social Care for Older People in England and Wales

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Modernisation Muddles What is the Future of
Social Care for Older People in England and Wales

• Professor Robin Means
• Associate Dean (Research)
• Faculty of Health Social Care
• University of the West of England, Bristol

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THE TALK WITH COVER

• Reflections on community care/social care.
• Examples of rapid policy change or what I have
  called modernisation muddles.
• Exploration of whether this merely reflects a
  continuation of a long standing policy problem,
  namely the artificial divide between what is
  health care? and what is social care?.
• An argument that social care is merely a
  reflection of more deep seated trends in
  organisational culture which encourages a kind of
  policy attention deficit syndrome?.
• A discussion with you about whether or not social
  care futures will be different in England and
  Wales.

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COMMUNITY CARE

• The Health Service and Community Care Act 1990
  gave the lead agency role in community care to
  social services authorities for all the main
  core groups of service users and required the
  stimulation of a mixed economy of care through
  encouraging independent providers.
• At a strategic level, this was to be achieved
  through the publication of community care plans
  on the basis of wide consultation with key
  agencies and groups, including service users and
  carers. Care management was to be used at the
  operational level to ensure service users were
  offered flexible packages of care which were to
  draw heavily upon the independent sector.

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SINCE THEN

• Establishment of Welsh and Scottish assemblies.
• Splitting up of social services authorities in
  England with separate arrangements for children
  and adults (Directors of Adult Social Care
  Services).
• Community care plans have long gone.
• We no longer talk in terms of lead agency roles.
• And the replacement of the term community care
  with social care.

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FROM COMMUNITY CARE TO SOCIAL CARE? WHY?

• There was no formal announcement but rather
  governments just started to talk about social
  care and not community care.
• It could simply be because social care is seen as
  a term more easily encompassing Care Homes as
  well as care in the community compared to the
  term community care.
• Or it could be because no statement have ever
  been made about lead agency roles in social care
  rather than community care and hence it can be
  presented more easily as subservient to health.

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MODERNISATION MUDDLES IN ENGLAND HEALTH

• White Paper on the NHS (DH, 1997)
• NHS Plan (DH, 2000)
• White Paper on Public Health (DH, 2001)
• White Paper on Community Services (DH, 2006)

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KEY CHANGES INCLUDE

• Primary Care Trusts
• Foundation Hospitals
• Market of Independent Health Care Providers
• Locally Based Commissioning
• Money following the Patient
• Endless Reconfigurations of Services, Boundaries,
  Roles and Responsibilities
• NHS Financial Crisis
• Endless changes in Workforce Planning

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MODERNISATION MUDDLES IN ENGLAND SOCIAL CARE

• Single assessment process
• Fair access to services
• Intermediate care services
• Delayed discharge policy
• Direct payments
• Care Trusts (for the few)
• Reconfigurations of inspection arrangements
• Changes to the funding of Long Term Care (free
  nursing care)
• Financial pressures
• Less organisational disruption

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WHAT IS HEALTH CARE? WHAT IS SOCIAL CARE?

• Section 21 of the National Assistance Act 1948
• it should be the duty of every local
  authorityto provide residential accommodation
  for persons who are by reasons of age, infirmity
  or any other circumstances in need of care and
  attention which is not otherwise available to
  them.
• The act offered no definition of care and
  attention
• Over time it has come to include people in
  ever failing
• health
• The act is still in operation today

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WHAT IS HEALTH CARE? WHAT IS SOCIAL CARE?

• Huws Jones (1952, p. 19) spoke of the emergence
  of a group of older people stranded in no mans
  land between the Regional Hospital Board and the
  local welfare department not ill enough for
  one, not well enough for the other.
• (see also Lewis, 2001a)

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WHAT IS HEALTH CARE? WHAT IS SOCIAL CARE?

• The Ministry of Health clarified the
  responsibilities of local authorities under the
  1948 National Assistance Act as being
• Care of the otherwise active resident in a
  welfare home.
• Care of the infirm (including the senile) who
  may need help
• in dressing, toilet etc, and may need to
  live on the ground
• floor because they cannot manage stairs and
  may spend
• part of the day in bed (or longer periods in
  bad weather).
• Care of those elderly persons in a welfare
  home who have
• to take to bed and are not expected to live
  more than a
• few weeks (Ministry of Health, 1957).
• (Ministry of Health, 1957, Circular 14/57)

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WHAT IS HEALTH CARE? WHAT IS SOCIAL CARE?

• Boundaries between health and social care
  continued to shift throughout the period,
  1971-1993. They shifted mainly in one direction.
  Social Services were expected to take on
  responsibilities for older people who would once
  have been deemed to lie well outside any
  definition of in need of care and attention.
  Not only this but they were expected to work ever
  more closely with health over the planning and
  delivery of services, especially at the community
  level. The resultant tensions and arguments
  outlined were inevitable.
• (Means et al, 2002, p. 95)

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WHAT IS HEALTH CARE? WHAT IS SOCIAL CARE?

• If you needed to be conveyed by ambulance you
  went to the hospital. If you could be conveyed
  by a minibus or by care with someone then you
  would go to the day care centre, a staffed day
  care centre. Whereas if you could go by car or
  you were ambulant, you went to the day centre
  that was run by voluntary (organisations).
• (Means et al, 2002)

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WHAT IS HEALTH CARE? WHAT IS SOCIAL CARE?

• The majority Report of Royal Commission on Long
  Term Care (1999) argued for free personal care on
  the grounds that no logical distinction could be
  made either between health care and social care
  or between those services which should be free
  and those that should be means tested.
• Older person with cancer gets free NHS
  treatment
• Older person with dementia gets largely means
  tested
• social care support

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WHAT IS HEALTH CARE, WHAT IS SOCIAL CARE?

• Definitions of Personal Care
• Personal care would cover all direct care related
  to
• Personal toilet (washing, bathing, skin care,
  personal presentation, dressing and undressing
  and skin care)
• Eating and drinking (as opposed to obtaining and
  preparing food and drink)
• Managing urinary and bowel functions (including
  maintaining continence and managing
  incontinence)
• Managing problems associated with immobility
• Management of prescribed treatment (e.g.
  administration and monitoring medication)
• Behaviour management and ensuring personal safety
  (e.g. for those with cognitive impairment
  minimising stress and risk).

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WHAT IS HEALTH CARE, WHAT IS SOCIAL CARE?

• Definitions of Personal Care
• Personal care also includes the associated
  teaching, enabling, psychological support from a
  knowledgeable and skilled professional and
  assistance with cognitive functions (e.g.
  reminding, for those with dementia) that are
  needed either to enable a person to do these
  things for himself/herself or to enable a
  relative to do them for him/her.
• (Sutherland Report, 1999a, p. 68)

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WHAT IS HEALTH CARE? WHAT IS SOCIAL CARE?

• Does the Wanless Review (2006) help to resolve
  the health and social care boundary issue?
• The review acknowledges the importance of this
  issue but
• tends to define social care in terms of
  existing LA services,
• namely residential/nursing care, domiciliary
  care and day
• care i.e. it takes a pragmatic definition.
• The review is very knowing about health and
  social care
• tensions the health and social care
  boundary is far less
• clear-cut in reality that the funding regime
  impliesit is
• sometimes very difficult to distinguish
  between the needs
• of someone receiving free continuing NHS
  care (including free
• accommodation) and someone with very high
  personal care
• needs due to, for instance, severe
  dementia. (p. 104)

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THE CULTURE OF THE NEW CAPITALISM

• Sennett (2006) in the Culture of the New
  Capitalism profiles how the information
  revolution across the private and public sectors
  has centralised power in the hands of senior
  executives and prompted their belief that they
  know enough to command immediate change from the
  top. Furthermore, he argues that in this MP3
  kind of institution (p. 172), staff become
  overwhelmed by a mixture of information and
  instruction made all the worse by the tendency of
  such technology to disable the craft of
  communication (p. 173). Added to this is the
  speed of innovation and change in the New
  Capitalism with obsolescence and uselessness
  faced by many staff and not just those with the
  least skills and education.

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THE CULTURE OF THE NEW CAPITALISM

• Sennett believes New Labour fell into the trap of
  embracing the MP3 culture in its public reform
  agenda without recognising all its limitations in
  terms of maintaining commitment from staff and
  the trust of the public.

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THE CULTURE OF THE NEW CAPITALISM

• Interestingly, he is able to show how work
  policies show the same frenetic pattern as those
  for community care
• The initial policies about work were good job
  training and counselling, industrial safety,
  work-family issues all squarely addressed. Each
  year, however, there were more policies or
  different policies which reformed the previous
  policies which reformed the mess Labour had
  inherited. As the policies kept coming, the
  public trust in them eroded. Within the councils
  of government, the manufacture of ever-new
  policies appeared as an effort to learn from the
  actions previously taken to the public, the
  policy factory seemed to indicate the government
  lacked commitment to any particular course of
  action (p. 174).

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WELSH POLICY MUDDLES (OR MUCH NEEDED
MODERNISATION?)

• Welsh Assembly Government (2006) A Strategy for
  Social Services in Wales over the next Decade
• Welsh Assembly Government (2003) The Strategy for
  Older People in Wales
• Welsh Assembly Government (2006) National Service
  Framework for Older People in Wales
• Welsh Assembly Government (2007) Fulfilled Lives,
  Supportive Communities
• Welsh Assembly Government (2003) Health, Social
  Care and Well-being Strategies
• National Assembly for Wales (2005) Report of
  Review of the Interface between Health and Social
  Care
• Welsh Assembly Government (2005) Designed for
  Life Creating World Class Health and Social Care
  for Wales in the 21st Century

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WELSH POLICY MUDDLES (OR MUCH NEEDED
MODERNISATION?)

• There is a strong sense that a hegemonic
  discourse of a One Scotland or a One Wales is
  in the making a discourse and ideology centred
  on nationalised and indigenous versions of
  neo-liberalism. Welsh and Scottish social
  policies are tied to particular national
  visions of a better Wales or a new Scotland. But
  these aspirations are also largely New Labour
  UK-wide ambitions a particular language has
  come to dominate in both countries, that both
  celebrates devolution and speaks of and to a
  sense of newness and modernity.
• (Mooney and Williams, 2006)

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WELSH POLICY MUDDLES (OR MUCH NEEDED
MODERNISATION?)

• Devolution may express a sense of national
  difference in Wales and Scotland but the
  existence of the UK state continues to frame much
  of social policy practice even while this is
  being re-badged as Scottish and Welsh. The dual
  national universes of the devolved nations and
  Britain here are reflected in successive attitude
  surveys that show continuing and widespread
  public support for the key institutions of the
  British welfare state (and little in the way of
  support for the modernised version currently
  being constructed by New Labour) across the whole
  of the UK.
• (Mooney and Williams, 2006)

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HOW SIMILAR? HOW DIFFERENT?